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STATE OF CALIFORNIf WATER RESOURCES CONTRO' 'AOARD FORM 'B': UNDEMROUND STORAGE TANK PRO -116AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - G MARK ONLY F-11 ❑ CHANGE OF INFORMATION 7 PERMANENTLYC NEWPERMIT 3 RENEWALPERMIT 5 K 10 ❑ ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED/2,10 If FARM TANK-YES❑ NO N W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK IDN B. MANUFACTURED BY: C.YEAR INSTALLED i/L,/pv 0. TANK CAPACITY IN GALLONS: �D D 11. TANK CONTENTS IF IRA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑ B.3 CHEMICALPRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Ef 2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEVIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 SIEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ 9100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑1 RUBBERUNED ❑2 ALKYD UNING F-] 3 EPDXY LINING ❑4 PHENOUCUNING C INTERIOR [__j 5 GLASS UNING dUNUNED ❑"KNOWN ❑ IS UNING MATERIAL COMPATIBLE WRH IW ANOL? %METH ❑YES ❑ NO D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VI WRAP L]4 FIBERGLASS REINFORCEDPLASRC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U. 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEELCLAD W/FRP A U 8 1009 METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 5 UNKNOWN A U "OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ( P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 1 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED PTE LAST USED(MO/YR) 2. ESTIMA ED QUANTITY OF 3. AS TANK FILLED WITH VIA SU E REMAINING IN G AL RT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N 3 ; I poZ3 G d6 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY E PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE FERMI EXPIRATION DATE CHECKN PEflMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: dWk FORM B(6-29-88) THIS FORM MUST BE ACCO MPANIEB'BY A FACILITY/SITE APPLICATION, FORM'A',UNIES8 A ...1RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY